The home health aide caring for a home bound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
Listen for the presence of bowel sounds.
Teach the client about foods high in fiber.
Administer a prescribed dose of a laxative.
Assist the client in drinking warm prune juice.
The Correct Answer is D
Choice A Reason: Listening for the presence of bowel sounds is not a task that the home health aide can perform, as it requires a stethoscope and clinical judgment. This task is within the scope of practice of the nurse, who should assess the client's bowel function and abdominal status.
Choice B Reason: Teaching the client about foods high in fiber is not a task that the home health aide can perform, as it requires knowledge and education skills. This task is within the scope of practice of the nurse, who should provide dietary advice and counseling to the client and their family.
Choice C Reason: Administering a prescribed dose of a laxative is not a task that the home health aide can perform, as it requires medication administration skills and authority. This task is within the scope of practice of the nurse, who should check the medication order, verify the dosage and route, and document the administration.
Choice D Reason: Assisting the client to drink warm prune juice is a task that the home health aide can perform, as it requires basic care and assistance skills. This task is appropriate for the home health aide, who should encourage fluid intake and offer natural remedies for constipation, such as prune juice, which has laxative effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Choosing to send another nurse who is more receptive is not a good option, as it may create
resentment and conflict among the staff. The older nurse may feel discriminated against or excluded, and the other nurse may feel burdened or pressured. The nurse manager should try to engage and motivate the older nurse to attend the in-service session, as it is important for her professional development and patient safety.
Choice B Reason: Asking the nurse why she thinks there is no need for an in-service program about these emergencies may sound confrontational or accusatory and may put the nurse on the defensive. The nurse manager should avoid making assumptions or judgments about the nurse's attitude or beliefs, and instead try to understand her perspective and address any barriers or misconceptions.
Choice C Reason: Informing the older nurse that inservice is not optional and her scheduled attendance is mandatory may be true, but it may also sound authoritarian or coercive, and may undermine the nurse's autonomy or dignity. The nurse-manager should avoid using threats or ultimatums, and instead try to explain the rationale and benefits of the inservice session, and solicit the nurse's input or feedback.
Choice D Reason: Encouraging the nurse to share her concerns and discuss ways to prepare for such emergencies is the best option, as it shows respect and empathy for the nurse, and fosters a collaborative and supportive
relationship. The nurse-manager should use active listening and open-ended questions, and provide relevant information and resources to help the nurse overcome her fears or doubts, and enhance her confidence and competence.
Correct Answer is B
Explanation
A) This client has a mild fever, which may indicate an infection or inflammation. This is a potential complication of enteral feedings, but it is not the most urgent situation. The nurse should monitor the client's vital signs, assess the feeding tube site, and notify the provider if the fever persists or worsens.
B) This client has signs of uremic encephalopathy, which is a life-threatening condition caused by the accumulation of toxins in the brain due to impaired renal function. The nurse should intervene immediately to prevent further
neurological damage and possible coma or death. The nurse should assess the client's level of consciousness, check the blood pressure and urine output, and prepare to administer dialysis or other treatments as ordered by the provider.
C) This client has heat stroke, which is a serious condition that can lead to dehydration, electrolyte imbalance, and organ damage. However, the client is receiving a normal saline IV fluid bolus, which is an appropriate intervention to restore fluid volume and correct sodium levels. The nurse should continue to monitor the client's vital signs, skin
temperature, and urine output, and watch for signs of fluid overload or cerebral edema.
D) This client has hyperemesis gravidarum, which is a severe form of nausea and vomiting during pregnancy that can lead to dehydration, malnutrition, and electrolyte imbalance. However, the client is receiving an infusion of Ringer's Lactate, which is an isotonic solution that can replenish fluid and electrolyte losses. The nurse should continue to monitor the client's vital signs, weight, and intake and output, and administer antiemetics or other medications as ordered by the provider.
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